University of Kentucky College of Medicine and Lexington Veterans Administration, Lexington, Ky.
University of Kentucky College of Medicine and Lexington Veterans Administration, Lexington, Ky.
J Vasc Surg Venous Lymphat Disord. 2018 Nov;6(6):737-740. doi: 10.1016/j.jvsv.2018.05.021. Epub 2018 Aug 17.
Lymphocele (LC) and lymphocutaneous fistula (LF) are infrequent but serious complications that occur when lymphatics are disrupted during a vascular procedure. Conservative management with bed rest, extremity elevation, aspiration, and pressure dressing is often ineffective. This study evaluated the effectiveness of isosulfan blue (ISB) to identify disrupted lymphatics for ligation.
Between 1998 and 2016, there were 33 lymphatic complications treated with ISB-directed ligation in 32 patients. The patients' records were retrospectively reviewed, recording demographics, comorbid conditions, index vascular operation causing the lymphatic complication, details of the procedure done to treat the lymphatic complication, and outcomes. In each patient, between 1 and 3 mL of ISB was injected in the subcutaneous tissue of the interdigital web space. The wound associated with the lymphatic complication was opened. The appearance of dye within the wound identified disrupted lymphatic ducts for suture ligation.
The lymphatic complications were either LC (11 [33%]) or LF (22 [66%]) and were associated with femoral vein harvest (9), great saphenous vein harvest (8), exposure of femoral arteries (13), creation of an upper extremity fistula (1), repeated femoral access for coronary angiography, or excision of an LC (1). Most patients were male (66%), and the mean age was 56.8 ± 13.1 years. In comparing patients with LF and LC, the diagnosis of LF was made earlier (13.8 ± 7.0 days vs 23.4 ± 14.1 days; P = .02), and treatment occurred sooner for LF than for LC (22.1 ± 8.1 days vs 48.8 ± 51.2 days; P = .02). In all patients, ISB identified one or more disrupted lymphatics. The appearance of the ISB dye within the wound after injection was rapid, often within 5 to 10 minutes. After ligation of the lymphatics, most wounds were closed primarily (26 [79%]), but a muscle flap (5 [15%]), negative pressure dressing (1 [3%]), and dressing changes (1 [3%]) were also used. Wound healing was achieved in all patients on average 32.5 ± 21.5 days after lymphatic ligation.
The current series is one of the largest reported experiences using ISB to identify injured lymphatics responsible for LC or LF. Lymphatic complications after a vascular procedure usually occur within 3 weeks of the index vascular procedure, with LF being identified and treated earlier than LC. ISB injection rapidly identifies disrupted extremity lymphatics. Ligation of these lymphatics results in reliable resolution of the lymphatic complication.
淋巴管瘤（LC）和淋巴皮肤瘘（LF）是在血管手术过程中淋巴管破裂时发生的罕见但严重的并发症。卧床休息、抬高肢体、抽吸和加压包扎等保守治疗通常无效。本研究评估了异硫蓝（ISB）用于识别结扎受损淋巴管的有效性。
1998 年至 2016 年，32 例患者中有 33 例因血管操作导致的淋巴并发症接受 ISB 引导的结扎治疗。回顾性分析患者的病历，记录人口统计学、合并症、导致淋巴并发症的指数血管操作、治疗淋巴并发症的详细过程和结果。在每个患者的指间蹼皮下组织中注射 1 至 3 毫升 ISB。打开与淋巴并发症相关的伤口。伤口内染料的出现可识别用于缝合结扎的受损淋巴导管。
淋巴并发症为 LC（11 例[33%]）或 LF（22 例[66%]），与股静脉采集（9 例）、大隐静脉采集（8 例）、股动脉暴露（13 例）、上肢瘘管形成（1 例）、重复股动脉冠状动脉造影或 LC 切除（1 例）有关。大多数患者为男性（66%），平均年龄为 56.8±13.1 岁。比较 LF 和 LC 患者，LF 的诊断更早（13.8±7.0 天 vs. 23.4±14.1 天；P=0.02），LF 的治疗时间也早于 LC（22.1±8.1 天 vs. 48.8±51.2 天；P=0.02）。在所有患者中，ISB 均识别出一条或多条受损的淋巴管。注射后 ISB 染料在伤口内的出现非常迅速，通常在 5 至 10 分钟内。结扎淋巴管后，大多数伤口均一期缝合（26 例[79%]），但也使用了肌瓣（5 例[15%]）、负压敷料（1 例[3%]）和换药（1 例[3%]）。所有患者平均在淋巴管结扎后 32.5±21.5 天愈合。
本系列是使用 ISB 识别导致 LC 或 LF 的受损淋巴管的最大报道之一。血管手术后的淋巴并发症通常在指数血管手术后 3 周内发生，LF 的诊断和治疗早于 LC。ISB 注射可快速识别受损的四肢淋巴管。结扎这些淋巴管可可靠地解决淋巴并发症。
